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fe <br /> .. Dr (e <br /> pal�$� •� STATE ID NUMBER 00000010752001 <br /> APPLICATION FOR PERMIT TO OPERAT U DERGROUND STORAGE TANK <br /> F ) O1 NEW PERMIT ( 1 05 RENEWED PERMIT NK L ( ) 09 DELETE FROM FILE (NO FEET <br /> ( ) 02 CONDITIONAL PERMIT ( ) 06 AMENDED PERMIT ( ) 08 NGE (NO SURCHARGE) <br /> I OWNER <br /> NAME(COPPORATION.INOIVIDUAL OR PUBLIC AGENCY) PUBLIC AGENCY ONLY <br /> PETERSON MFG. CO. SUBSIDIARY K ( ) 01 FED ( ) 02 STATE ( 1 03 LOCAL <br /> STREET ADDRESS CITY STATE ZIP <br /> 2626 E. 25TH ST LOS ANGELES CA 90058 <br /> II FACILITY <br /> FACILITY NAME DEALER/FOREMAN/SUPERVISOR <br /> PETERSON MFG. CO. HARVEY ALLEN <br /> STPEET ADDRESS NEAREST CROSS STREET <br /> 2403 NAVY DRIVE FRESNO <br /> CITY COUNTY ZIP <br /> STOCKTON SAN JOAQUIN 95206 <br /> MAILING ADDRESS CITY STATE ZIP <br /> 2403 NAVY DRIVE STOCKTON CA 95206 <br /> PHONE W/AREA CODE TYPE OF BUSINESS <br /> 209-462-5818 ( ) 01 GASOLINE STATION (X) 02 OTHER RENDERING <br /> NUMBER OF CONTAINERS RURAL AREAS ONLY TOWNSHIP RANGE SECTION <br /> 1 <br /> III 24 HOUR EMERGENCY CONTACT PERSON <br /> OATS: NAME(LAST NAME FIRST) AND PHONE W/AREA CODE NIGHTS: NAME(IAZT NAME FIRST) AND PHONE W/APEA CODE <br /> ALLEN> HARVEY 209-462-5818 ALLEN, HARVEY 209-957-4664 <br /> COMPLETE THE FOLLOWING ON A SEPARATE FORM FOR EACH CONTAINER <br /> IV DESCRIPTION <br /> A. (X) 01 TANK ( 1 04 OTHER: CONTAINER NUMBER 18 <br /> B. MANUFACTURER (IF APPROPRIATE): YEAR MFG: C. YEAR INSTALLED fX) UNKNOWN <br /> D. CONTAINER CAPACITY: 1000 GALLONS [ ) UNKNOWN E. DOES THE CONTAINER STORE: [ ) 01 WASTE (X) 02 PRODUCT <br /> F. DOES THE CONTAINER STORE MOTOR VEHICLE FUEL OR WASTE OIL ? (X) 01 YES ( ) 02 NO IF YES CHECK APPROPRIATE BOX(ES)' <br /> (X) 01 UNLEADED ( ) 02 REGULAR ( 1 03 PREMIUM ( ) 04 DIESEL ( ) 05 WASTE OIL ( 1 06 OTHER <br /> V CONTAINER CONSTRUCTION <br /> A. THICKNESS OF PRIMARY CONTAINMENT: f ) GAUGE ( ) INCHES ( ) CM (X) UNKNOWN <br /> B. ( ) 01 VAULTED (LOCATED IN AN UNDERGROUND VAULT) f ) 02 NON-VAULTED (X) 03 UNKNOWN <br /> C. ( ) 01 DOUBLE WALLED ( l 02 SINGLE WALLED ( ] 03 LINED <br /> D. ( ) 01 CARBON STEEL ( 1 02 STAINLESS STEEL ( 1 03 FIBERGLASS ( 1 04 POLYVINYL CHLORIDE ( 1 05 CONCRETE <br /> ( 1 06 ALUMINUM ( ) 07 STEEL CLAD ( ] 08 BRONZE t l 09 COMPOSITE ( ) 10 NON-METALLIC <br /> (X) 12 UNKNOWN ( ) 13 OTHER: <br /> HSC04-070185 (10/18/85) PAGE 1 <br /> Y w <br /> STATE ID NUMBER 00000010752001 <br /> CONTAINER CONSTRUCTION <br /> E. ( ) 01 RUBBER LINED ( ) 02 ALKYD LINING f ) 03 EPDXY LINING f ) 04 PHENOLIC LINING f 1 05 GLASS LINING <br /> ( ) 07 UNLINED (X) 08 UNKNOWN ( ) 09 OTHER: <br /> F. ( ) 01 POLYETHLENE WRAP ( 1 02 VINYL WRAPPING ( ) 03 CATHODIC PROTECTION (X) 04 UNKNOWN ( 1 05 NONE <br /> ( ) 06 TAR OR ASPHALT ( 1 09 OTHER: <br /> VI PIPING <br /> A. ABOVEGROUND PIPING: f ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE ( ) 05 SUCTION ( ) 06 UNKNOWN ( ) 07 NONE <br /> B. UNDERGROUND PIPING: ( ) 01 DOUBLE-WALLED PIPE ( ) 02 CONCRETE-LINED TRENCH ( ) 03 GRAVITY <br /> (CHECK APPROPRIATE BOX(ES) ( ) 04 PRESSURE (X) 05 SUCTION ( l 06 UNKNOWN ( 1 07 NONE <br /> VII LEAK DETECTION <br /> `{ 1 01 VISUAL (X) 02 STOCK INVENTORY ( l 04 VAPOR SNIFF WELLS ( ] 05 SENSOR INSTRUMENT <br /> ( ) 06 GROUND WATER MONITORING WELLS ( ) 07 PRESSURE TEST ( ) 09 NONE ( ) 10 OTHER: <br /> VIII CHEMICAL. COMPOSITION OF MATERIALS STORED IN UNDERGROUND CONTAINERS <br /> IF YOU CHECKED YES TO :V-F YOU ARE NOT REQUIRED TO COMPLETE THIS SECTION <br /> CURRENTLY PREVIOUSLY DELETE CAS# (IF KNOWN) CHEMICAL (DO NOT USE COMMERCIAL NAME) <br /> STORED STORED <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( 1 01 ( ) 02 ' ( ) 03 <br /> ( ) Ol ( ) 02 ( ) 03 <br /> ( ) <br /> al ( ) 02 ( ) 03 <br /> ( 1 <br /> 01 ( ) 02 ( ) 03 <br /> ( ] 01 ( l 02 f 1 03 <br /> ( 1 01 f T 02 ( ) 03 <br /> l l 03 ( l 02 ( ) 03 <br />